The authors concluded that perineal exercises during pregnancy may reduce the development of post-partum urinary incontinence. Effects during pregnancy were unclear. There were limitations in the reporting of this review, but overall the authors’ cautious conclusions reflected the limited evidence from a small number of diverse studies.

To evaluate the effects of perineal exercises during pregnancy on the prevention of urinary incontinence.

MEDLINE, LILACS, SciELO, SCIRUS and The Cochrane Library were searched for studies published between 1966 and 2007. Search terms were reported. Reference lists of the selected studies were screened.

Randomised controlled trials (RCTs) that evaluated perineal exercise-only interventions during pregnancy in low risk obstetric populations (primiparas or nulliparas) were eligible for inclusion. Studies that evaluated vaginal cones, electrical stimulation or biofeedback were excluded. Review outcomes were self-reported symptoms of urinary incontinence during and/or after pregnancy, pelvic floor strength and quality of life. The review assessed outcomes during the third trimester of pregnancy and at six weeks to three months post-partum.

In all of the included studies, perineal exercises were started in the 20th week of gestation. Studies used different exercise protocols and daily instructions in how to perform the exercises (details were reported). Where reported, control interventions included information on perineal muscles or no information. Two studies reported that a percentage of patients in the control group (approximately 20% and 50%) performed perineal exercises.

The mean age of participants ranged from 23 to 29 years. Inclusion criteria for participants varied. Some studies included only women with no history of incontinence; another included women with increased bladder neck mobility and excluded women with only urge-incontinence. Studies used different definitions for continence and its severity. All studies used women’s self report of incontinence provided in questionnaire; one study also carried out a pad test.

Two reviewers independently screened titles and abstracts. No further details of study selection methods were reported.

Two reviewers assessed validity using the Jadad criteria (randomisation, blinding and reporting of withdrawals). Disagreements were resolved by discussion. Studies that scored 2 or fewer points out of a maximum possible 5 were classified as low quality.

Odds ratios and 95% confidence intervals (CI) were calculated for outcomes.

The authors did not state how many reviewers performed the data extraction.

Pooled odds ratios and 95% CIs were calculated using a fixed-effect method in the absence of significant heterogeneity; otherwise, a random-effects model was used. Heterogeneity was assessed using the ² and I² statistics. Data from studies that used different methods to assess outcomes were not pooled.

Four RCTs were included (n=675). Studies scored 3 out of 5 on the Jadad criteria. All used adequate allocation concealment. None were double blinded. In all studies the investigator was blinded to the treatment group.

Incontinence :Perineal exercises were associated with a statistically significant reduction in the risk of urinary incontinence from six weeks to three months post partum compared with control (odds ratio 0.45, 95% CI: 0.31 to 0.66, p<0.0001; three studies, n=603). No significant heterogeneity was found. There was no statistically significant difference between treatment groups in the development of urinary incontinence in the 34th or 35th week of gestation (odds ratio 0.13, 95% CI: 0.00 to 3.77, p=0.23; two studies, n=373). Significant heterogeneity was found (p=0.02, I²=82%).

One study not included in meta-analyses reported that perineal exercises were associated with a statistically significant reduction in the risk of incontinence in the 35th week of gestation (p=0.043), six weeks (p=0.032) and six months post-partum (p=0.044), but there was no treatment difference at 12 months.

There was no difference in the risk of incontinence according to type of birth.

Muscle strength: Two of four studies that assessed perineal muscle strength reported a significant improvement in perineal exercise groups; the two other studies reported no significant difference between treatment groups.

Quality of life: One study reported a significant improvement at three months postpartum in the general health domain of the short-form-36 (SF-36) in the exercise training group.

Perineal exercises during pregnancy may reduce the development of post-partum urinary incontinence. Effects during pregnancy were unclear.

The review question was clearly stated and inclusion criteria were appropriately defined. Several relevant sources were searched, but it was unclear whether attempts were made to minimise publication and language biases. Methods were used to minimise reviewer errors and bias in the assessment of validity and parts of the study selection process, but it was unclear whether similar steps were taken during the extraction of data. Only RCTs were included, validity was assessed and results were reported. Appropriate methods were used for the meta-analyses and heterogeneity was assessed. There were limitations in the reporting of this review, but overall the authors’ cautious conclusions reflected limited evidence from a small number of diverse studies.

Practice: The authors did not state any implications for practice.

Research: The authors stated that further studies were needed that clearly defined the inclusion and exclusion criteria, removed other risk factors for urinary incontinence, evaluated specific perineal exercise protocols designed to strengthen pelvic floor muscles and examined the influence of perineal exercises in control groups and the influence of regular practice. Studies should assess longer term outcomes (at least three months) and quality of life.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.